RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXX	CASE:  PD-2017-05657
BRANCH OF SERVICE:  air force	SEPARATION DATE:  20080102

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Communication-Computer Operator and Network Infrastructure System Craftsman, medically separated for “chest pain and dyspnea, asthma-like illness requiring bronchodilators” with a disability rating of 10%.

CI CONTENTION:  “Conditions at separation supports a higher rating as indicated by the VA examination.”  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the Physical Evaluation Board (PEB) to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20071030	VARD - 20100316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chest Pain and Dyspnea… 	6602	10%	Asthma (Also Claimed as Associated Residuals Coccidiodomycosis)	6835-6602	30%	20081212	
Pulmonary Coccidiodomycosis without Residuals Symptoms 	Not Unfitting					
Gastroesophageal Reflux Disease [GERD]		GERD	7346	10%		
Allergic Rhinitis		Season Allergic Rhinitis	6522	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  
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Chest Pain and Dyspnea.  The PEB combined the chest pain and dyspnea/asthma-like illness requiring bronchodilators as a single unfitting condition coded 6602 and rated 10%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the chest pain and dyspnea/ asthma-like illness are presented together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI suffered an acute pulmonary illness attributed to coccidiodomycosis (desert soil fungus infection) in February 2004.  The PEB found the CI fit for duty in 2006, however, he continued to have chest pain and dyspnea and was subsequently diagnosed with asthma in February 2006.  He was treated with fluticasone (inhalational steroid), albuterol (inhalational bronchodilator), Advair (steroid/bronchodilator combination) and montelukast (oral indirect-acting bronchodilator).  He was then reentered into the MEB/PEB process.   Loratadine (antihistamine) was added for a possible allergy component.  

A pulmonary function test (PFT) on 8 January 2007, 12 months before separation, revealed an FEV-1 at 72.4 % predicted to 108.4% predicted post bronchodilation, and an FEV-1/FVC of 76.3% to 100.9% post bronchodilation.  On 11 January 2007, he had bronchitis that was treated with oral prednisone and Augmentin (antibiotic).  A CT scan on 1 March 2007 demonstrated a right upper lobe nodule measuring 1.5 x 1 cm, which was the same or slightly smaller when compared to a prior examination.  The impression was a stable right upper lobe nodule with a history of coccidiomycosis.  At a family practice clinic visit on 29 March 2007, the provider documented that a gastrointestinal component (reflux) responded to Aciphex and cardiology evaluations were negative.  On 9 May 2007, a treatment entry indicated Xopenex (inhalational bronchodilator) lessened the severity of the asthma to mild symptoms, and a negative cardiology evaluation for the atypical chest pain was confirmed.  The examiner noted a history of costochondritis (inflammation of the cartilage at the rib/breastbone junction) may have contributed intermittently to the chest pain; therefore Mobic (nonsteroidal anti-inflammatory drug) was resumed.  At a pulmonary clinic visit on 21 June 2007, baseline spirometry was normal and there was no significant airway reaction to a methacholine challenge test, which was interpreted as “no signs of asthma.”  

A barium swallow on 11 July 2007 revealed gastroesophageal reflux, and a stress echocardiogram on 1 August 2007 was unremarkable with no chest pain or ischemic EKG changes.  Wall motion at rest and with stress was normal, as was left ventricular size and function, and mitral/aortic valves.  A revised temporary P4 profile was issued on 2 August 2007 with restrictions of no running for physical training or fitness testing.  During a pulmonary follow-up on 8 August 2007, the provider noted the CI could not tolerate the Advair medication due to depressive symptoms. The commander’s statement dated 16 August 2007 indicated his medical condition periodically limited movement and restricted him to his desk approximately 1 day per month.  Furthermore, he required medication, which prevented him from running or exercising. 

During the 24 August 2007 MEB NARSUM examination, 4 months prior to separation, the CI reported chest pain and dyspnea on exertion, and that he was unable to pass the fitness test.  The pulmonary evaluation was normal and the aforementioned PFT results were referenced.  Current asthma medications included Pulmicort (inhalational anti-inflammatory), Xopenex, and Singulair (montelukast).  He also took Prilosec (proton pump inhibitor) for reflux as well as antihistamines for allergies. The examiner noted physical findings “per attached notes,” and stated that: cardiology concluded a non-cardiac etiology for the symptoms; the CI was on an antihistamine and anti-inflammatory combination for his allergies; and the gastroenterologist’s opinion was that the reflux was an unlikely cause of his chest pain pattern.  The examiner further added that no specialists had been able to attribute the CI’s symptoms to post- coccidioidomycosis, and despite negative PFTs, the diagnosis of asthma was made as there was a partial response at times to asthma medication.  However, it did not explain the full constellation of symptoms, and the cumulative assessments of the specialists did not allow a more specific diagnosis for his atypical chest pain.  A gastroenterology evaluation on 21 September 2007, 3 months before separation, recorded Singulair, fluticasone, and salmeterol (inhalational bronchodilator) as active medications. 

At the 12 December 2008 VA Compensation and Pension (C&P) examination, 12 months after separation, the CI reported his asthma condition limited the ability to exercise unduly, which would bring on an attack. The examiner documented asthma and seasonal allergies currently well-controlled by Singulair and Qvar (inhalational anti-inflammatory).  A PFT on 18 December 2008 recorded “expiratory airflows within normal limits,” but did not provide percentages. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma 10%, coded 6602 (asthma, bronchial).  The VA rated the asthma 100%, also coded 6602, based on the VA examination, citing systemic “oral” Qvar steroid (immune-suppressive medication).  A subsequent VA Rating Decision reduced the asthma rating to 30%, citing an unmistakable error as Qvar is an inhaled corticosteroid and not a systemic “oral” steroid. 

A 30% rating stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  The panel agreed that the MEB NARSUM and VA examinations documented the CI’s requirement and use of daily oral bronchodilator therapy and inhalational anti-inflammatory medication to support a 30% rating.  There were no PFT results to support an alternative 30% rating, and  a higher 60% rating was not justified in the absence of monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic corticosteroids.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the asthma, coded 6602.

The panel determined that the atypical chest pain condition was separately unfitting, albeit neither the profile nor the commander’s statement explicitly addressed the condition; however, its exact cause was not determined and the closest diagnosis to possibly explain a major portion of the atypical chest pain is the asthma-like illness, which is unfitting, and rated accordingly.  Therefore, an additional rating for the atypical chest pain condition would invoke pyramiding IAW VASRD §4.14, which is to be avoided.

Contended PEB Conditions:  Pulmonary Coccidiodomycosis without Residuals Symptoms, GERD, and Allergic Rhinitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled proximate to separation, implicated in the commander’s statement, or failed retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the asthma, the panel recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the contended pulmonary coccidiodomycosis without residuals symptoms, GERD, and allergic rhinitis, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chest Pain and Dyspnea, Asthma-Like Illness Requiring Bronchodilators	6602	30%	

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05657.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.